SOAP Note Examples
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Since the 1970s, the SOAP note has become one of the most widely used formats of documentation across multiple sectors of healthcare. It’s common to see specific SOAP note examples for all types of clinicians and health professionals — including SOAP notes for occupational therapy, SOAP notes for physical therapists, as well as SOAP notes for medical doctors and for pharmacists.
Wondering how to write a SOAP note and looking for therapy SOAP note examples? Read on, and we’ll share some helpful SOAP note examples.
Given the usefulness of the SOAP note format and its widespread adoption, it’s essential for mental health clinicians to understand how to interpret and write SOAP notes.
SOAP stands for Subjective, Objective, Assessment and Plan. SOAP notes have been used since the 1970s.
The intention behind the way SOAP notes for therapy are written was to create an organized space to record clinical analysis from the treating provider, a shared language for communication between collaborating providers, and a uniform template to store information for all who would later refer to the record.
Quality therapy SOAP notes can help mental health clinicians to clearly organize their clinical determinations, ensure consistent insurance payouts for their practice and clearly communicate with other collaborating healthcare providers.
This article includes SOAP note examples to help you better understand how to write SOAP notes.
SOAP note format
Reviewing a sample SOAP note is one of the best ways to learn the framework and to evaluate the quality of one’s own documentation.
When examining therapy SOAP note examples, it’s of primary importance to understand what information each section is seeking to capture. It’s also helpful to consider the questions that each section is prompting one to answer.
S=Subjective
This section of the note is focused on the experiences, views and emotions of the client from their perspective. This includes the client’s chief complaint, as well as the presenting problem and reported history.
The chief complaint or presenting problem sets the focus for the rest of the documentation, as the majority of the note will typically relate in some way to the core presenting problems.
Relevant direct quotes from the client are also included here as they can help to effectively capture the current state of the client.
Questions to answer in the subjective section:
1. What are the core problems the client believes they are facing?
2. What symptoms and resulting life challenges did the client report?
3. What history and context did the client report that would be essential to include?
4. What specific statements did the client make that help illustrate their current experience?
O=Objective
The focus of this section is set on facts and observable evidence.
Descriptive clinical observation and standardized assessment are the priority.
Mental status measures, observable behaviors, assessment results and related clinical or medical reports are what the clinician should have in mind here. Any risk assessment would also be included.
Questions to answer in the objective section:
1. What were the behaviors, nonverbal expressions, gestures, postures, and overall presentation of the client?
2. What was the client’s mood and affect?
3. What was the nature of the client’s thought processes, thought content and orientation to their environment?
4. How did the client respond during the session and during particular topics of discussion?
What assessment scores were recorded or discussed during the session?
A=Assessment
This section is using clinical judgment and analysis to provide a combined summary of the Subjective and Objective sections. This is where the clinician’s knowledge can really shine as they interpret the subjective reports of the client, the objective data and note determinations related to clinical themes or DSM criteria.
This should not be a mere repeat of the S & O sections, but rather a synthesis of those sections that displays a greater understanding of the client as revealed during that particular therapy session.
Questions to answer in the assessment section:
1. Which clinical themes are present?
2. What diagnostic criteria are being met by the client?
3. What do the subjective reports of the client and objective observations really show about the current state of the client?
4. Are there any rule out diagnoses that should be noted?
P=Plan
In light of the observations and interpretations above, this section should outline specific next steps with the client that will help move them towards their goals.
The section can also include a summary of client progress towards their determined objectives.
Any specific adjustments to the treatment plan and near-term targets should be noted as well.
Questions to answer in the plan section:
1. What progress or lack of progress has the client made towards their self determined goals?
2. What specific steps has the client committed to work on as homework or during the next session?
3. What specific interventions or treatment plan changes will the clinician be focused on in the upcoming sessions?
Next, let’s look at some therapy SOAP note examples.
3 helpful SOAP note examples:
Therapy SOAP note example #1
Subjective
Client reported ongoing worry and anticipatory anxiety. They stated “It is hard for me to get excited to go anywhere because I’m always expecting the worst.” They also noted extreme restlessness, muscle tension and an average of 3-4 hours of sleep per night.
Objective
Client’s speech was rapid and rambling. Their thought processes were tangential. They frequently avoided discussing their anxiety by diverting to unrelated topics of discussion. They were fidgety throughout the session. Their mood was anxious with congruent affect. They denied any SI/HI or psychosis. They were oriented x 4. Writer conducted the GAD-7 assessment with the client and reviewed the severe score result of 18 with them.
Assessment
Client continues to experience severe symptoms congruent with their Generalized Anxiety Disorder diagnosis. Their frequent rumination, hypervigilance, physical distress and worry is disruptive to their self care, social life and occupation. Writer will continue to assess for the possibility of Social Anxiety Disorder given client’s previous mention of anxiety related relational difficulties.
Plan
Client has made minor attempts to implement some of the coping skills discussed with Writer but continues to present with an overall avoidance of deeper intervention for their anxiety. Client has not conducted previously agreed upon homework activities. Writer will continue to build rapport and trust with the client. Writer will provide basic anxiety psychoeducation and teach mindfulness based relaxation techniques. Writer will introduce the model of CBT to help prepare the client for deeper work on their anxious cognitions, behaviors and emotions.
Therapy SOAP note example #2
Subjective
Client complained of depression and low self-esteem. She endorsed symptoms of low motivation, lack of interest in activities, social isolation, guilt and shame, low mood, loss of appetite and inability to concentrate. She reported experiencing these symptoms consistently for the past seven months. Client reported “I’ve never felt this sad before. It feels like I can’t get myself motivated to do anything that I used to do.”
Objective
Client participated in the video telehealth call from her home. The address is on file. Client presented as disheveled and conducted the appointment while still lying in her bed. She wavered between looking at the camera and lying on her back looking up at the ceiling. Client’s speech was slow and halting. Her attention and concentration were within normal limits. She was forthcoming with information and displayed reasonable insight. She denied any HI or psychosis. She reported passive SI last week but denied any current SI, plans or intent. Writer encouraged her to call 911 or 988 if her SI intensifies and causes concern for her safety. She acknowledged this.
Assessment
The Client meets full criteria for Major Depressive Disorder. Her physical health and relationships are significantly impacted by the severity of her symptoms. The client’s mood and activity levels have declined in recent weeks. She has not reported or displayed any signs of mania and thus has not met criteria for Bipolar I or II.
Plan
The Client will benefit from behavioral activation. Writer will provide education about the MDD diagnosis, CBT and the benefits of behavioral activation for early stages of depression treatment. Writer will work with Client to develop an initial weekly plan of activities.
Therapy SOAP note example #3
Subjective
Client continues to participate in therapy to deal with symptoms of acute stress related to a recent car accident. He reported ongoing intrusive symptoms of nightmares, flashbacks and triggering reminders of the event. He noted avoidance of all driving and avoiding travel by roads as much as possible. He stated “I haven’t driven again since the accident. I don’t know if I will ever be able to drive again.” He reported ongoing challenges with hypervigilance, low mood, sleep difficulties, startle response, irritability, social isolation, shame, self-blame and inability to think positively about the future. Client reported that the symptoms have harmed his relationship with his partner.
Objective
Client was given the PCL-5 assessment and scored a 49 which Writer reviewed with the Client. Client appeared uneasy, uncomfortable and hypervigilant during session. He frequently shifted positions in his chair, picked at his nails and anxiously looked out the window. His mood was anxious with congruent affect. His speech, thought processes and thought content were normal. His insight and judgment were fair. Client was cooperative but was guarded at times when speaking about memories of the accident.
Assessment
Client continues to experience the symptoms of trauma and acute stress. His symptoms directly correlate to the recent car accident that occurred three weeks ago. These symptoms were not present in his life prior to the accident. His relationship issues, emotional difficulties and avoidance behaviors all started immediately after the accident. He meets full criteria for Acute Stress Disorder and will be reassessed after 1 month post-accident to determine if he meets criteria for PTSD. He shows good insight and is receptive to therapeutic intervention.
Plan
Client has been receptive to education and initial stabilizing coping skills taught by Writer. Client has started to utilize the coping skills despite being frustrated by his persisting trauma symptoms. Writer and Client have discussed EMDR therapy and agreed to begin the intervention as soon as possible. Writer has explained risks and benefits of EMDR to client. Writer will begin initial preparation phases of EMDR, while continuing to assess client’s stability and capacity to tolerate difficult emotions.
How SimplePractice makes SOAP notes even easier
SimplePractice is the HIPAA-compliant practice management software with easy and secure therapy notes, progress notes, SOAP notes, and other note-taking templates built into the platform. Using SimplePractice makes it fast and simple to access your notes and fill them out after each session.
With built in SOAP notes templates in the SimplePractice software, you’ll never find yourself searching for SOAP note examples ever again.
If your EHR doesn’t have built-in SOAP note examples and templates, you can download a SOAP note template to keep on hand, or make your own following the guidelines we provided above.
If you’ve been considering switching to a fully integrated, HIPAA-compliant practice management software, SimplePractice gives you everything you need to streamline your note-taking process. You’ll get more organized and run a fully paperless practice.
You can access SOAP note examples and templates from the robust template library, use the “load previous note” feature to easily update your notes each session, and send follow-up information about your sessions to your clients through the client portal.
Used by over 178,000 clinicians nationwide, SimplePractice is consistently rated as the very best practice management software for therapists, speech-language pathologists, occupational therapists, and other practitioners in the health and wellness industry.
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